Updated March 29, 2020, 11:00 p.m. PT. The following sections have been updated in the past 24 hours by the AAOS: Background; Guidance for outpatient clinics and elective surgery

Source: AAOS

The Academy is sharing important ophthalmology-specific information related to the novel coronavirus, referred to as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was previously known by the provisional name 2019-nCoV. The highly contagious virus can cause a severe respiratory disease known as COVID-19.

This page is principally authored by James Chodosh, MD, MPH, with assistance from Gary N. Holland, MD, and Steven Yeh, MD.

What you need to know

  • Several reports suggest the virus can cause a mild follicular conjunctivitis otherwise indistinguishable from other viral causes, and possibly be transmitted by aerosol contact with conjunctiva.
  • Patients who present to ophthalmologists for conjunctivitis who also have fever and respiratory symptoms including cough and shortness of breath, and who have recently traveled internationally, particularly to areas with known outbreaks (China, Iran, Italy and South Korea, or to hotspots within the United States), or with family members recently back from one of these areas, could represent cases of COVID-19.
  • The Academy and federal officials recommend protection for the mouthnose and eyes when caring for patients potentially infected with SARS-CoV-2.
  • The virus that causes COVID-19 is very likely susceptible to the same alcohol- and bleach-based disinfectants that ophthalmologists commonly use to disinfect ophthalmic instruments and office furniture. To prevent SARS-CoV-2 transmission, the same disinfection practices already used to prevent office-based spread of other viral pathogens are recommended before and after every patient encounter.

Source: AAOS

Ophthalmology ties

Two published reports and a more recent news article suggest the virus can cause conjunctivitis. Thus, it is possible that SARS-CoV-2 is transmitted by aerosol contact with the conjunctiva.

  • In a Journal of Medical Virology study of 30 patients hospitalized for COVID-19 in China, 1 had conjunctivitis. That patient—and not the other 29—had SARS-CoV-2 in their ocular secretions. This suggests that SARS-CoV-2 can infect the conjunctiva and cause conjunctivitis, and virus particles are present in ocular secretions.
  • In a larger study published in the New England Journal of Medicine, researchers documented “conjunctival congestion” in 9 of 1,099 patients (0.8%) with laboratory-confirmed COVID-19 from 30 hospitals across China.
  • In a story just out from CNN, a registered nurse in a nursing home reported that red eye was a common early sign in elderly patients who then became sick with COVID-19.

While it appears conjunctivitis is an uncommon event as it relates to COVID-19, other forms of conjunctivitis are common. Affected patients frequently present to eye clinics or emergency departments. That increases the likelihood ophthalmologists may be the first providers to evaluate patients possibly infected with COVID-19.

Therefore, protecting your mouthnose (e.g., an N-95 mask) and eyes (e.g., goggles or shield) is recommended when caring for patients potentially infected with COVID-19. In addition, slit-lamp breath shields (e.g., here ) are helpful for protecting both health care workers and patients from respiratory illness. Free slit-lamp breath shields are being offered by some manufacturers, including Topcon and Zeiss.

Source: AAOS

Recommended protocols when scheduling or seeing patients

  • In response to the state of emergency declared at the federal level and in multiple states as of March 14, 2020, as well as the US. Surgeon General’s warning, clinicians should postpone those outpatient visits and procedures that can be safely delayed, particularly in elderly patients and those with comorbidities.
  • Reschedule appointments for patients with nonurgent ophthalmic problems, and avoid using equipment that cannot be safely disinfected, such as some visual field analyzers.
  • If the office setup permits, patients who come to an appointment should be asked prior to entering the waiting room about respiratory illness and whether they or a family member have traveled to a high-risk area in the past 14 days. If they answer yes to either question, they should be sent home and told to speak to their primary care physician.
  • Keep the waiting room as empty as possible, advise seated patients to remain at least 6 feet from one another. As much as prudent, reduce the visits of the most vulnerable patients.
  • If a patient with known COVID-19 infection needs urgent ophthalmic care, if possible they should be sent to a hospital or center equipped to deal with COVID-19 and urgent eye conditions, ideally in a hospital setting under hospital infection control conditions.
  • The use of commercially available slit-lamp barriers or breath shields is encouraged, as they may provide a measure of added protection against the virus. These barriers do not, however, prevent contamination of equipment and surfaces on the patient’s side of the barrier, which may then be touched by staff and other patients and lead to transmission. Homemade barriers may be more difficult to sterilize and could be a source of contamination. In general, barriers are not a substitute for careful cleaning of equipment between patients and asking those patients who cough, sneeze, or have flu-like symptoms to wear masks during examination.
  • To further decrease the risk of any virus transmission, ophthalmologists should inform their patients that they will speak as little as possible during the slit-lamp examination, and request that the patient also refrain from talking.

Source: AAOS

Telemedicine services

The CMS and HHS have allowed for the expanded use of telehealth services during the COVID-19 public health crisis. According to the CMS, this option for services applies whether or not patients have COVID-19 symptoms. There are 3 options for telehealth and other communications-based technology services: telephone services, internet-based consultation or telemedicine exam. For complete and updated information, visit the Academy’s Coding for Phone Calls, Internet and Telehealth Consultations.

Interim guidance for triage of ophthalmology patients

Clinical Situation
Patient Management / Precautions
1. Routine ophthalmic issues and previously scheduled appointments
  • Routine problems should be deferred and previously scheduled appointments should be canceled.
  • Appointments should be rescheduled only upon clearance from public health authorities.
  • Refill all necessary medications.
2.Urgent ophthalmology appointment for a patient with no respiratory illness symptoms, no fever, and no COVID-19 risk factors
  • Standard precautions* only.
  • Added precaution of not speaking during slit-lamp biomicroscopic examinations is appropriate.
  • Mask, gown and gloves are not routinely required for patient or clinician but may reduced asymptomatic transmission.
3. Urgent ophthalmic problem in a patient with respiratory illness symptoms, but no fever or other COVID-19 risk factor
  • The patient can be seen in the eye clinic.
  • The patient should be placed in an examination lane immediately with the door closed and asked to wear a surgical mask. The treating ophthalmologist and health care personnel require surgical masks.
  • Gowns, gloves and eye protection are recommended. An N-95 mask should be worn if a procedure is planned that will result in aerosolized virus.
  • The examining room must be disinfected after examination.
4. Urgent ophthalmic problem in a patient who is at high risk for COVID-19
  • The patient is best sent to the ER or other hospital-based facility equipped to evaluate for, and manage, COVID-19.
  • If the patient has an urgent eye problem based on screening questions, the facility should be one that is equipped to provide eye care in the hospital setting.
  • If SARS-CoV-2 infection is confirmed, CDC (or hospital) guidelines for care of suspected COVID-19 patients should be followed for health care facility preparation and infection control.
  • Eye care is best provided in the hospital setting. Transmission precautions for treating ophthalmologists include wearing a surgical mask, gown, gloves and eye protection (face shield or goggles, if available).
5. Urgent ophthalmic problem in a patient with documented COVID-19 (or person under investigation [PUI])
  • The patient should remain in the hospital setting if possible.
  • Determine whether the eye problem is urgent based on screening questions, and if so, evaluation and management should be in the hospital setting.
  • If the patient is not hospitalized at the time of referral, the patient is best referred to the ER or other hospital-based facility equipped to manage both COVID-19 and eye care.
  • CDC or hospital guidelines should be followed for care of COVID-19 patients.
  • Transmission precautions for treating ophthalmologists include wearing an N-95 mask, gown, gloves and eye protection (face shield or goggles, as above).

[Read the American College of Surgeon’s guidelines for operating on COVID-19 patients]

*  Standard (Universal) Precautions: Minimum infection prevention precautions that apply to all patient care, regardless of suspected or confirmed infection status of patient, in any health care setting (e.g., hand hygiene, cough etiquette, use of PPE, cleaning and disinfecting environmental surfaces). See CDC: Standard Precautions.

†  Currently, there are national and international shortages of PPE, which also warrant consideration. Excessive use of PPE may deplete the supply of critical equipment required in the future for patients with COVID-19 as the epidemic expands. Use of PPE should be considered on an institutional and case-by-case basis; universal usage for all patient encounters is not appropriate.

‡ Transmission Precautions: Second tier of basic infection control, used in addition to Standard Precautions when patients have diseases that can spread through contact, droplet or airborne routes, requiring specific precautions based on the circumstances of a case. Transmission precautions are required for cases of suspected COVID-19. See CDC: Transmission-Based Precautions.


Source: AAOS